this is in course hero needs to be revised so that it is not plagiarized
To Prepare
· Review this week's Learning Resources and consider the insights they provide related to ears, nose, and throat.
· Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
· Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
· Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
· Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Case Study on Daniel Rivera coughing USE Shadow Health On Danny River 8 year old Puerto Rican
Document: Provider Notes – NURS 6512
Name:
Focused Exam: Cough
Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. When you are ready to submit your documentation, ‘Save As’ with this title format: “[LastName_FirstName] Shadow Health Documentation Template – FE_Cough – NURS 6512”
Subjective
Objective
Assessment
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Shadow Health (SH) Assignments
Tips for Success
1.) Use only Google Chrome browser, other browsers do not work with SH and the text to
talk feature will only work in Chrome. All other programs should be closed when running
Shadow Health as it is similar to gaming software and uses a lot of computer resources.
2.) Register for Shadow Health using the access code from the Walden Bookstore via the
link in the Blackboard classroom.
3.) Complete the orientation in Shadow Health to ensure aspects of the program are
understood. Do not wait to get started as there is a learning curve and exams may take
longer than the posted estimates depending on technology and Internet availability.
4.) Be sure to read and understand the rubric so you know how you are being graded.
Rubrics are located in Course Information within the Blackboard Course.
5.) Complete the reading and weekly information in the course. Think about questions you
would ask the patient – writing them down will help you as you move through the exam.
Refer to the text for guidance and suggested questions to ensure a thorough assessment.
6.) Complete the assignment thoroughly. See below for documentation help.
7.) Review the overview for subjective and objective assessment. Make note of areas that are
missing or need to be improved. REOPEN the assignment so you can address the
missing areas of assessment. You DO NOT need to keep starting a new assignment each
time changes need to be made. It will save you time to re-open and add to the assignment.
8.) Once the assignment is complete, be sure to submit the assignment for grading. Please
note: If you complete more than one attempt you must select the attempt you wish to
submit for grading. It is the student’s responsibility to submit the correct assignment for
grading. Faculty will not search through attempts when grading.
9.) The Blackboard grade book will not indicate an assignment has been submitted as SH
and Blackboard to not communicate. Faculty will go into SH, grade the assignment, and
place feedback and the grade in the Blackboard grade book.
10). Shadow Health grades are partially calculated using the Digital Clinical Experience
(DCE) score (See the grading rubrics in the Blackboard course for details.). The DCE is
calculated by Shadow Health and is based on the questions and areas assessed.
Documentation Help:
As you can see from the rubric, you are graded on narrative documentation as well as your
overall DCE score. For the highest chance of obtaining all points, follow the advice below.
1.) Make sure you know where to record the narrative documentation. It can look a little
different in each exam.
This screen shot shows where the narrative documentation is located in the Health History:
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Use the shift assessment tab and fill documentation in on each of the required boxes.
Here is an example of the location of the narrative documentation in the body system exams:
2.) Once you end the exam you can check your documentation and see the Model
Documentation or documentation prompts. The overview page provides your overall
score, click on documentation on the left-hand side.
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This will take you to where you can review your documentation and the Model Documentation
or documentation prompts.
3.) The example below demonstrates the screen appearance when reviewing the
documentation. Student documentation will appear on the left and the Model
Documentation or documentation prompts will appear on the right.
Notes
Student Documentation Model Documentation
Example of Subjective Data:
Head: Reports headaches that occur weekly with
reading in the past year. The headache lasts a few
hours and is relieved with acetaminophen and sleep.
Headaches are described as a “tight and throbbing
feeling behind the eyes.” Denies head and neck
trauma, brain cancer, migraines, seizures, dizziness,
hearing loss, and syncope. Ears: Denies difficulty
hearing, tinnitus, ear pain, discharge, and loss of
balance. Denies history of chronic otitis media and
perforated tympanic membrane. Eyes: Complains of
blurred vision associated with . . . . .
Subjective:
Subjective information is information the patient or
care giver tells you. It is information related to the
illness and or review of systems. This is also the type
of information related to the PQRST (See Jarvis text
for additional information about this topic.) of the
current illness or issue. All subjective information
should be together and not mixed with objective data.
Example of Objective Data:
Head: Normocephalic, atraumatic with no masses to
palpation. Full distribution of hair on scalp, coarse hair
noted on lateral face, chin, and upper lip. Eyebrows
intact. Facial expression relaxed and symmetric
without tics or drooping. No maxillary or frontal sinus
tenderness. TMJ vertical and lateral movements
smooth and symmetric. No clicking or crepitus. Ears:
Normal shape without deformities, Darwin tubercle,
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redness or scaling. Auditory canals without edema or
erythema. Tympanic membranes bilaterally pearly gray
and intact with cone of light and bony landmarks
visualized. No lesions noted. Hearing intact to whisper
test.
Objective:
Objective information is the data measured, felt, heard,
assessed, and/or smelled during the assessment. In
other words, all the objective findings of the exam.
Objective information should be documented all
together in one place and not mixed with subjective
information.
4.) Finally, compare your documentation with the model documentation. DO NOT copy the
model documentation or examples from the text or SH. This is plagiarism and
disciplinary action will be taken. Instead, use the Model Documentation from Shadow
Health and the sample documentation in the text as guides to make sure you are covering
the required pieces of the assessment.
5.) Document in a clear, concise manor. Keep subjective and objective information separate
and always begin with subjective information. (See the definition of subjective and
objective data in the student documentation in the photo above). This is a foundation of
documentation and is necessary for ease of review of notes and communication.
6.) Lastly, have fun, make the most of the learning experience. Shadow Health is a place to
learn and explore in a safe environment. Documentation may not be perfect and that is
fine. It takes time to get phrasing and elements correct. The main thing is that you are
learning.
Notes